The influence of completeness supporting examination and discharge summary procedure to suitability of severity level determination in tertiary referral hospital

Abstract

Background: The implementation of the national health insurance program to fulfill the payment system related to a claim needs the documentation of services in the discharge summary. The objective of this study was to determine the influence of completeness supporting examination and discharge summary procedure to suitability of severity level determination in tertiary referral hospitals. 
Methods: This was an analytical study with cross-sectional design. The data were collected from observation toward inpatient’s discharge summary. Ninety-nine samples were taken by simple random sampling technique. 
Results: The results of the statistical significance test showed that the congeniality between the supporting examination results and procedure (p<0.0001) and the completeness of secondary diagnosis in discharge summary (p<0.0001) had an influence on the suitability of severity levels. 
Conclusion: Completeness supporting examination and discharge summary procedure can influence severity level.

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